Linking Systems to Strategy - Key Challenges


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Deborah Roche
Ministry of Health

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Linking Systems to Strategy - Key Challenges

  1. 1. Linking Systems to Strategy Health Information New Zealand Seminar 30 September 2008 Deborah Roche Deputy Director-General Ministry of Health
  2. 2. Overview <ul><li>The big picture </li></ul><ul><li>Key challenges </li></ul><ul><li>Addressing the challenges </li></ul>
  3. 3. The Government has invested significantly in the health system Vote Health has had a real average increase in funding per capita of 4.9% each year since 2001/02, but still well below OECD median spend per capita (by 20% in 2005) Prevention and Public Health Spending Per Capita in 2005 (Adjusted for Differences in Cost of Living) NZ’s spending on prevention and public health is above the OECD average Source: OECD 2007
  4. 4. This investment is showing real dividends - significant indicators of health status are improving… <ul><li>LE ↑ 3.5yr males & 2.2yrs females over the last 9 years </li></ul><ul><li>Reduced deaths from CVD: </li></ul><ul><li>↓ 39% from 1990 to 2004 </li></ul><ul><li>↓ 10% from 2000 to 2004 </li></ul>Source: NZ health surveys, 1996/97, 2002/03 & 2006/07 People rating their health status very good or excellent (age standardised by gender) increased in 2006/07 from previous surveys
  5. 5. … and there is some evidence that health inequalities are reducing. <ul><li>Inequalities have reduced in some areas… </li></ul><ul><li>Life expectancy gap </li></ul><ul><li>Māori & non-Māori: </li></ul><ul><li>- 9.8 years 1995−97 </li></ul><ul><li>- 7.3 years 2000−02 </li></ul><ul><li>- 7 years 2006 </li></ul><ul><li>Infant mortality </li></ul><ul><li>Maori rate ↓ 43% while total rate ↓ 28% </li></ul><ul><li>-11.5 per 1000 live births 1996 </li></ul><ul><li>- 6.6 per 1000 live births 2005 </li></ul><ul><li>All cause mortality </li></ul><ul><li>1996-99 - 2001-04: absolute inequality in all cause mortality (actual SMR difference) decreased, more so for Maori than for Pacific ethnic groups </li></ul>
  6. 6. An ageing population will add to financial pressures <ul><li>Number of over-65s will more than double, especially ‘old old’ </li></ul><ul><li>Greater impact on rural areas </li></ul><ul><li>Maori, Pacific and Asian populations remain younger </li></ul><ul><li>Ageing labour force & rural factor </li></ul><ul><li>Increasingly diverse needs, with a growing demand for care and support </li></ul>OECD predict that ageing alone will increase total health-care spending by an average of nearly 2 percent of GDP over the period 2000 – 2050. But $100m question - will the ‘new elderly’ be fit and healthy or frail and dependent?
  7. 7. Impact of population ageing on DHBs
  8. 8. The burden of long term conditions is rising and will increase strain on finance… <ul><li>Long term conditions </li></ul><ul><li>2 out of 3 adults and 1 in 3 children diagnosed by a Dr with a health condition that lasted, or was expected to last six months or more (MoH 2008) </li></ul><ul><li>7 long term conditions (cancer, coronary heart disease, stroke, diabetes, chronic kidney disease, alzheimer’s disease, and mental illness) account for at least 80% of the total burden and cost of long-term disease in New Zealand </li></ul><ul><li>Cancer rate increasing </li></ul><ul><li>CVD mortality declining </li></ul><ul><li>Rising burden of stroke-related disability </li></ul><ul><li>40-50% increase in diabetes prevalence </li></ul><ul><li>Prevalence of Alzheimer’s will double by 2031 </li></ul>
  9. 9. … although improving in some cases, current lifestyle trends are likely to continue to exacerbate chronic illness for some time Obesity rates have increased … <ul><li>Smoking rates are falling… </li></ul>Adult daily smoking 26.7% m, 23.8% f, 1996/97 24.0% m, 22.9% f, 2002/03 20.0% m, 17.5% f, 2006/07 But are still high! 34.8% Maori men, 40.1% Maori women We have a real opportunity…. * Modifiable risk factors * Upstream investment * Improved interventions * New models of care Adult obesity 16.6% m, 20.6% f, 1996/97 23.4% m, 24.8% f, 2002/03 24.8% m, 26.0% f, 2006/07 And disparities are striking! 43.2% Maori men and women
  10. 10. And we have many other challenges to address, for example… <ul><li>Workforce </li></ul><ul><li>Ageing </li></ul><ul><li>Growing demand </li></ul><ul><li>Global labour market </li></ul><ul><li>Above inflation settlements </li></ul><ul><li>Nature of work </li></ul>Rising public expectations “ Rising public expectations have their own momentum. Rising expectations lead to improvements, which in turn creates pressure for more improvements” (Rankin et al 2007) <ul><li>Technological advances changing </li></ul><ul><li>benefits and care delivery eg. </li></ul><ul><li>Telemedicine </li></ul><ul><li>Drugs </li></ul><ul><li>Miniaturisation of medical devices </li></ul><ul><li>Tissue engineering, genomics </li></ul><ul><li>nanotechnology </li></ul><ul><li> </li></ul><ul><li>Stubborn and persistent inequalities </li></ul><ul><li>Examples include avoidable mortality, breast cancer screening, infant mortality, cervical cancer screening </li></ul><ul><li>Differential access to health services </li></ul><ul><li>Complex causal factors </li></ul><ul><li> </li></ul>
  11. 11. The more fundamental and longer-run demand and cost pressures are significant <ul><li>Healthcare costs have risen steadily over the past decade across the OECD </li></ul><ul><li>In most countries real health spend has increased at a faster rate than real GDP </li></ul><ul><li>Combination of expansions of the health “offer” as well as technology advance, rising drug costs </li></ul>Historic Trends 2000 2050 <ul><li>OECD predicts that total spending on health and long-term care will rise across OECD countries by 3.5 to 6% points of GDP between 2005 and 2050 </li></ul>Future Predictions 0 2 4 6 8 Projected Range of Average Increases of Healthcare Spend across OECD countries % points increase in GDP <ul><li>Public health spend will grow from 6.4% to 10 -13% of GDP by 2050 </li></ul><ul><li>Likely slowdowns in general economic growth and claims from other spending departments likely to reduce room for manoeuvre for health funding </li></ul>Implications for New Zealand
  12. 12. It is likely that better patient care saves money… <ul><li>Dudley PCT in England: </li></ul><ul><li>PCTs, GPs and community nurses caring for 120 patients with 5 or more emergency admissions per annum </li></ul><ul><li>The results so far: </li></ul><ul><ul><li>Quality of life transformed </li></ul></ul><ul><ul><li>500+ emergency admissions avoided </li></ul></ul><ul><ul><li>Fewer acute beds in new hospital </li></ul></ul><ul><ul><li>Hospital budget under-spent </li></ul></ul><ul><li>In many health systems and clinical areas, we could well be in the LHS of the unit cost/quality curve </li></ul><ul><li>If not, we need to improve our systems or should we disinvest from these areas and reprioritise? </li></ul>Geisinger Health System, Pennsylvania USA – ↓20% hospital admissions with 7% savings, suggest links to operation of an EHR (Health Affairs, 2008) IZIP EHR, Czech Republic web-based EHR with 80% pop coverage, 8yrs for net benefit, suggest productivity gain of 74% measured as decrease in cost of using an EHR (European Commission 2006) Quality $ Cost per patient treatment
  13. 13. … part of this is a rigorous improvement in efficiency and productivity Source: Quarter 3 HBI reports, 2007/2008. <ul><li>Huge variations in activity exist: </li></ul><ul><ul><li>Average LOS below 3.5 days to almost 5 days across DHBs </li></ul></ul><ul><ul><li>Days case rates from below 45% to almost 65% </li></ul></ul><ul><ul><li>ED triage rates for category 2 patients from below 60% to 100% </li></ul></ul>
  14. 14. Service efficiency to service utilisation – a future model of care? <ul><li>Focus on prevention rather than cure </li></ul><ul><li>Care is proactive </li></ul><ul><li>Self-management an integral part of the delivery system </li></ul><ul><li>Care delivered by a health care team? </li></ul><ul><li>Care integrated across time, place and conditions </li></ul><ul><li>Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, </li></ul><ul><li>remote care technology </li></ul>The Long Term System Framework Long term service planning Quality improvement, safety & innovation Delivering improved performance System leadership and decision-making Developing the health workforce Developing health information systems Defining and developing new models of care
  15. 15. Some key challenges Possible information responses Current situation Targets and performance management provide clear organisational and professional challenge Comparative performance information available at individual, department and provider level Quality & safety: improvements in national system (QIC) Best practice process & learning available to drive improvement eg. decision support Information for the public and patients PHOs and local community providers show potential for bringing together services more effectively within the community Use mobile technologies to enhance care in deprived populations. Driving system co-operation and collaboration Common clinical pathways and business processes requiring common IT systems Implementing comprehensive preventive and public health programmes to stem rise in long term conditions Monitoring and surveillance information Information and care processes supporting self-care, early diagnosis & effective management
  16. 16. In the face of these challenges, there are competing views about the shape of the future NZ health system <ul><li>‘ Provider-centred’ </li></ul><ul><li>Current situation </li></ul><ul><li>Enhances individual departments and provider types but not whole of system </li></ul><ul><li>Results in silo health services </li></ul><ul><li>Works against horizontal and vertical integration </li></ul><ul><li>More costly system overall? </li></ul><ul><li>‘ Geographic’ </li></ul><ul><li>Optimal service configuration at district, regional and national levels – goal of LTSF </li></ul><ul><li>Encourage cooperation and collaboration amongst DHBs </li></ul><ul><li>Regional and national comprehensive service planning through LTSF </li></ul><ul><li>Focus on service sustainability </li></ul><ul><li>Will geographic approach address challenges? </li></ul><ul><li>‘ Person-centred’ </li></ul><ul><li>Focus on optimising patient pathways throughout the system </li></ul><ul><li>Engage consumer in care delivery </li></ul><ul><li>Supported self care for management of long term conditions </li></ul><ul><li>Meet future expectations about accessible, person-focussed health system </li></ul><ul><li>Focus on flexibility and adaptive system centred on individuals and families/whanau </li></ul>How can an innovative health system maximise the benefit for health, and the economy, of new (information) technology?